GI Bleed MDM

Posted on by tydotphrase

UGIB

+ abdominal pain + mixed coffee ground and bright red hematemesis + black stool per rectum
Has been admitted to ICU previously for similar presentation.

Given history and exam patient’s presentation most consistent with upper GI bleed possibly secondary to peptic ulcer disease or variceal bleeding.
I have low suspicion for aortoenteric fistula, ENT bleeding mimic, Boerhaave’s, Pulmonary bleeding mimic.

Workup: CBC, BMP, LFTs, Lipase, PT/INR, Type and Screen

Interventions:
Analgesia and antiemetic medications PRN
Protonix 40mg IVP
Octreotide 50mcg push –> 50 mcg/hr drip
Ceftriaxone 1 gram IV
Thiamine 100mg IM
PRBC transfusion

Findings:
Hb:
Glasgow-Blatchford Bleeding Score: ___ indicating need for admission.

Disposition: Admit to Step-Down Unit for close monitoring.

  • HPI
    Denies use of NSAIDs, ASA, or anticoagulant medication. Not taking iron or bismuth containing medications.
    Denies history of aortic graft.
    Denies history of liver disease. Denies alcohol abuse. No recent palmar erythema or new small, bright-red spots.
    Denies chest pain, shortness of breath, fever.
    Denies recent travel.

LGIB

Given history and exam patient’s presentation most consistent with Lower GI bleed possibly secondary to hemorrhoid or other nonemergent cause of bleeding.
I have low suspicion for Aortoenteric fistula, Upper GI Bleed, IBD, Mesenteric Ischemia, Rectal foreign body or ulcer.

Workup: CBC, BMP, PT/INR, Type and Screen

Disposition: Discharge. Hemodynamically stable with no gross blood on rectal exam. SRP and prompt PCP follow up.

  • “80% of lower GI bleeding will resolve spontaneously”
  • Cause generally not found (~50%)

PEARLS:

  • Protonix:
    • Increases pH which theoretically allows better clot formation in peptic ulcer bleeding through better platelet aggregation
    • Decreases need for surgery, length of stay
  • Octreotide
    • Inhibits secretion of gastric acid, reduces blood flow to the gastroduodenal mucosa, and causes splanchnic vasoconstriction.
    • No proven reduction in mortality
      • Still, if ill appearing and admitting to ICU consider gtt
  • Ceftriaxone
    • Cirrhosis overall creates an impaired immune system and patient’s are at increased risk of gut bacterial translocation during acute bleeding
  • Blood Transfusion
    • Transfuse if ≤7 grams/dL in most; ≤9 grams/dL in older patients or patients with comorbidities
  • Dispo Home?
    • “Very-low-risk patients (Less than 60 years old, no liver dz or other comorbidities, no red hematemesis, HDS in ED, nml labs) may be eligible for ED observation or be discharged home with adequate outpatient follow-up.”
  • Imaging and other studies:
    • EKG for possible cardiac ischemia 2/2 volume depletion
    • Consider CT Head noncon (for possible head trauma since AMS):
    • Consider CT abdomen w IV contrast (for possible intestinal perforation):
  • Steroids?
    • Maddrey’s Discriminant Function for Alcoholic Hepatitis (>30 suggests poor prognosis and benefits from steroid Tx)
  • Other meds?
    • “Tranexamic acid (TXA), an antifibrinolytic agent, has shown no benefit in the management UGI bleeding.”

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